Y CHILDREN’S ACADEMY/WELC
2015-2016 MONTHLY TUITION/PAYMENT FORM
CHILD’S NAME __________________________ TEACHER ______________ AM OR PM 4K
PARENT/GUARDIAN NAME _____________________ PHONE _______________ CELL ____________
ADDRESS ____________________________________________ EMAIL _______________________
PARENT/ GUARDIAN DATE OF BIRTH _____________________ AUTO PAY? Y or N (See back if Yes)
You may register for a mixture of full days and/or half days. Example: MTW= full day and Th =
half day. There is no drop in care and no credit will be given for missed days. If you require care on days
when the WELC is closed you must register for a NO School Fun Day separately. See registration
information on the back or call Laura Nagel, Y Academy Site Director, 262-522-4977 for more information.
Full Day Care is available from 7 AM until 6 PM on Waukesha Early Learning Center school days only.
Note: If you need care for more than 3 hours on any given day, you must register for a full day.
Transportation is provided to and from the WELC only on days school is in session and there must be a
total of at least 3 children registered daily in order for transportation to occur. Children must be dropped
off at the Y Academy by 8:30 AM for transportation to the 4K program, and no later than 11:15 AM for
transportation to the PM program. Per Waukesha School District guidelines, children enrolled in the PM 4K
program at the WELC will not have school on Friday’s and transportation is not provided.
Month
Monday
$80
September
$107
October
$134
November
$80
December
$80
January
$134
February
$80
March
$80
April
$107
May
$27
June
Half Day Care available
minutes each way).
Tuesday
Wednesday
Thursday
Friday
$134
$134
$107
$107
$107
$107
$107
$107
$107
$80
$80
$80
$107
$80
$80
$80
$107
$80
$107
$107
$107
$107
$107
$107
$107
$107
$107
$80
$107
$107
$107
$107
$134
$107
$107
$107
$273 hours
$54
$27
for
wrapped
around$27
the 4K
Total
Circle days Attending
$
M T
$
M T
$
M T
$
M T
$
M T
$
M T
$
M T
$
M T
$
M T
$ (including
M T
day
Time Attending
W Th F
W Th F
W Th F
W Th F
W Th F
W Th F
W Th F
W Th F
W Th F
W
Th F
transportation
time of 15
Half Day Care is available when 3 hours (including transportation time) or less wrapped around the 4K
Days
day isAttending
needed. this month: M T W TH F (circle)
$_____
Month
Monday
Tuesday
Wednesday
Thursday
Friday
Total
Circle days Attending Time Attending
September
October
November
December
January
February
March
April
May
June
$49
$65
$82
$49
$49
$82
$49
$49
$65
$16
$82
$65
$65
$65
$65
$65
$65
$65
$82
$16
$82
$65
$49
$49
$65
$65
$65
$65
$65
$32
$65
$65
$49
$49
$65
$65
$65
$65
$65
$16
$65
$65
$49
$49
$49
$65
$49
$65
$65
$16
$
$
$
$
$
$
$
$
$
$
M
M
M
M
M
M
M
M
M
M
T
T
T
T
T
T
T
T
T
T
W
W
W
W
W
W
W
W
W
W
Total amount due from page 1 $________
Th
Th
Th
Th
Th
Th
Th
Th
Th
Th
F
F
F
F
F
F
F
F
F
F
1
No School Day Registration- This is for students who are currently enrolled in our program that require
care on days when the Waukesha School District is closed. This is offered on site at the Y Academy. You
must pick up and drop off at the Y Academy.
Full Day $30/day Half Day $18/day
Total number of No School Fun Days registering for this month = _____X $_____= $_____
Month registering for = ___________
The total amount due this month (include pages 1 and 2) =$ _______
2015- 2016
Oct 29
Oct 30
Nov 25
Dec 23
Dec 28
Dec 29
Dec 30
Jan 22
Jan 25
No School Fun Days
Mar 25
Mar 28
Mar 29
Mar 30
Mar 31
Apr 1
Apr 25
June 9
June 10
Healthy Lunch: Please pack your
child a healthy non perishable lunch
and a water bottle each day. We will
provide healthy snacks. Lunch is not
available for this program.
Dress for Play: It is best for students
to dress for messy play and
movement. We are active during
extended care.
It is your responsibility to pay the tuition each month by the due date. We do not invoice or bill you.
Failure to pay the tuition on time may lead to dismissal from the program. Your child cannot attend if
payment is not received.
PAYMENT INFORMATION (PLEASE PRINT) CHECK SOURCE OF PAYMENT
CASH ___
CHECK #_____
(PAYABLE TO WAUKESHA YMCA)
CREDIT CARD: VISA ___ MASTERCARD ___ AMEX ___ DISCOVER ____
CREDIT CARD NUMBER
____________________________________
EXPIRATION DATE
_________
AUTHORIZED SIGNATURE
x_________________________________________
DATE
_______________________
SECURITY CODE
_____
Automatic Credit Card Withdraw
By checking this box, payee agrees to a monthly credit card payment plan for the entire school year. Payee
agrees to follow the noted charges on the credit card listed each month. Tuition automatically withdrawn from the
account listed on this form will be on the 15th of each month. If payee chooses to have an automatic withdraw, the
form must be completely filled out. It is payee’s responsibility to give a 2 week advanced, written notice, to the
Business Office if terminating the monthly credit card payment plan, or if the listed credit card information changes.
Any changes with the day of care or length of care must be approved by the Site Director before the 15 th of the previous
month.
Staff Only
Accounting must receive the automatic withdraw form.
Make a copy of the front page only and place in Laura Nagel’s mail box. If parent/guardian is participating in
automatic withdrawal please indicate that on the front page copy you give to the director by writing Auto Pay across the
top.
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